Objective To investigate the effect of obstructive sleep apnea (OSA) on behavioral problems in children and the association between them.

Methods A simple random sampling method was used to select 100 children aged 4 to 12 years for the case group. All of them were diagnosed with OSA through overnight polysomnography at the Sleep Medicine Center, West China Fourth Hospital, Sichuan University between October 2022 and October 2023. An additional 100 children without snoring symptoms and clinically evaluated and confirmed as not having OSA were enrolled as the control group. General demographic data of the participants were collected. The Caregiver Report Form of the Achenbach Child Behavior Checklist (CBCL) was used for behavioral problem assessment, and polysomnography data were collected. The chi-square/t test was used to analyze the inter-group differences in general data, the total score of behavioral problems, and scores for each dimension. Linear regression was performed to analyze the relationship between OSA and the total score for children's behavioral problems and those for the different dimensions. Logistic regression was applied to analyze the relationship between the obstructive apnoea-hypopnea index (OAHI) and behavioral problems in children with OSA. A logistic regression model integrating the OAHI × sex interaction term was constructed to evaluate the moderating effect of sex on the association between OAHI and behavioral problems.

Results No significant differences were observed in general demographic data between the case and control groups. The total score for behavioral problems and those for each dimension were higher in the case group than those in the control group, with the total score of the case group being 24.60 ± 1.55 and that of the control group being 8.85 ± 0.75 (P < 0.001). The results of the linear regression analysis showed a positive association between OSA and both the total score for behavioral problems (b = 16.01; 95% CI, 12.56-19.47) and those for each dimension. The results of the logistic regression analysis showed that, after adjusting for covariates, OAHI was a risk factor for behavioral problems in children with OSA (odds ratio OR = 1.17; 95% CI, 1.04-1.31). After stratification by sex and adjustment for covariates, the OR value of the effect of OAHI on behavioral problems was slightly higher in female participants (1.57) than that in male participants (1.21). The interaction effect analysis showed that sex moderated the association between OAHI and behavioral problems (OR = 1.64; 95% CI, 1.02-2.64; P = 0.04).

Conclusion Children with OSA are prone to developing behavioral problems. OAHI is a risk factor for behavioral problems in children with OSA, with a potentially greater effect observed in girls.